Healthcare Provider Details

I. General information

NPI: 1629302336
Provider Name (Legal Business Name): CHRISTIAN ANTHONY MACIEL LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHRISTIAN MACIEL LMFT

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91275 66TH AVE SUITE 500
MECCA CA
92254-6515
US

IV. Provider business mailing address

91275 66TH AVE SUITE 500
MECCA CA
92254-6515
US

V. Phone/Fax

Practice location:
  • Phone: 760-396-1249
  • Fax: 760-396-1253
Mailing address:
  • Phone: 760-396-1249
  • Fax: 760-396-1253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001725A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: